Social determinants of racial health inequities
Authors: Eric J Brandt
Journal: The Lancet Public Health (2023)

In The Lancet Public Health, Joshua D Bundy and colleagues report on how social determinants of health (SDoH) affect the association between race and premature mortality in a large cohort of adults in the USA.1Bundy JD Mills KT He H et al.Social determinants of health and premature death among adults in the USA from 1999 to 2018: a national cohort study.Lancet Public Health. 2023; 8: e422-e431Summary Full Text Full Text PDF Google Scholar By linking data from the US National Health and Nutrition Examination Survey from 1999 to 2018 to data from the National Death Index, the authors explored the associations between premature mortality (defined as death before 75 years of age) and SDoH across eight categories: employment status, family income-to-poverty ratio, food security, education level, health-care access, health insurance status, and being married or living with a partner. An increasing burden of SDoH was associated with higher risk of premature death. Additionally, after adjusting for age, gender, and number of unfavourable SDoH, no increased risk of mortality was observed among Black adults compared with White adults (hazard ratio 1·00 [95% CI 0·91–1·10] vs 1·59 [1·44–1·76] when adjusting only for age and gender). This finding that SDoH completely attenuated the association between Black race and mortality contributes to the evolving discussion of structural racism and its effects on health outcomes. Data such as these are an important addition to the recognition that underlying contributors to racial and ethnic inequities in health are driven by systemic racism rather than a biological effect of race or ethnicity.2Braveman P Parker Dominguez T Abandon "race." Focus on racism.Front Public Health. 2021; 9689462Crossref PubMed Scopus (14) Google Scholar Within clinical medicine, these findings are important as we move away from the use of race as a variable in clinical decision making.3Javed Z Haisum Maqsood M Yahya T et al.Race, racism, and cardiovascular health: applying a social determinants of health framework to racial/ethnic disparities in cardiovascular disease.Circ Cardiovasc Qual Outcomes. 2022; 15e007917Crossref Scopus (3) Google Scholar One recent example of this is a change in methods to calculate renal function. In 2021, a joint task force of the National Kidney Foundation and the American Society of Nephrology announced a new equation that removed race from equations to estimate renal function.4Delgado C Baweja M Crews DC et al.A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease.Am J Kidney Dis. 2022; 79 (e1): 268-288Summary Full Text Full Text PDF PubMed Scopus (137) Google Scholar Another example of equations that integrate race are the pooled cohort equations for estimating the risk for atherosclerotic cardiovascular events, which can produce widely different estimates across racial and ethnic groups.5Vasan RS van den Heuvel E Differences in estimates for 10-year risk of cardiovascular disease in Black versus White individuals with identical risk factor profiles using pooled cohort equations: an in silico cohort study.Lancet Digit Health. 2022; 4: e55-e63Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar These examples show that use of race as a proxy for other SDoH can result in varied outcomes. Whereas the previous equations to estimate renal function were more likely to lead to delayed care in managing advanced renal disease in Black adults, the pooled cohort equations are more likely to lead to earlier treatment or overtreatment for the prevention of atherosclerotic cardiovascular disease among Black adults. Both exemplify how use of race to make clinical decisions can lead to inequities in care delivery. Bundy and colleagues suggest that we should continue to improve our use of variables that better explain associations with health outcomes,6Vyas DA James A Kormos W Essien UR Revising the atherosclerotic cardiovascular disease calculator without race.Lancet Digit Health. 2022; 4: e4-e5Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar such as SDoH. Although structural racism causes inequities in health outcomes through SDoH, there remain important gaps that require additional consideration. First, additional studies could explore how individual SDoH are interconnected. Many SDoH occur within the same individuals, and Bundy and colleagues recognise their study's limitation in not comprehensively evaluating the interconnectedness of these determinants. They were able to show varying effect sizes for individual covariates when they were included in a single model; however, a more comprehensive understanding could better guide efforts to ameliorate the negative effects of SDoH. Second, this study does not address the problem of additional intermediary variables that lie between SDoH and death. SDoH are known to be connect to an increased prevalence of poor cardiovascular health markers, which can include hypertension, hyperglycaemia, and tobacco use, among others.7Connolly SD Lloyd-Jones DM Ning H Marino BS Pool LR Perak AM Social determinants of cardiovascular health in US adolescents: National Health and Nutrition Examination Surveys 1999 to 2014.J Am Heart Assoc. 2022; 11e026797Crossref Scopus (0) Google Scholar, 8Palacio A Mansi R Seo D et al.Social determinants of health score: does it help identify those at higher cardiovascular risk?.Am J Manag Care. 2020; 26: e312-e318Crossref PubMed Scopus (0) Google Scholar A more thorough understanding of these connections could inform on addressable factors to limit the negative consequences of SDoH. Furthermore, we need greater understanding of how SDoH affect outcomes and thereby create a cycle of increased risk for health-related events that subsequently worsen SDoH.9Velarde G Bravo-Jaimes K Brandt EJ et al.Locking the revolving door: racial disparities in cardiovascular disease.J Am Heart Assoc. 2023; 12e025271Crossref PubMed Scopus (0) Google Scholar Clinicians should be aware that SDoH, rather than individual clinical indicators, often have a larger impact on their patient population, thus are worthwhile to directly address from the clinical setting.10Frieden TR A framework for public health action: the health impact pyramid.Am J Public Health. 2010; 100: 590-595Crossref PubMed Scopus (969) Google Scholar In the clinical, public health, and research settings, continued work to gather more accurate SDoH data should be coupled with community-facing interventions to improve SDoH, including access to nutritious food, shelter, transportation to medical appointments, and others. SDoH can be addressed through many different pathways, and convening multidisciplinary teams of clinicians, social workers, and public health workers has the potential to change outcomes, not only for individual patients, but also outcomes for hospital systems. SDoH and racism clearly impact health outcomes; any remaining incompleteness in our understanding should not prohibit clinicians and health systems from acting now. EJB declares research funding from the National Institutes of Health and the Blue Cross Blue Shield of Michigan Foundation, and receipt of consulting fees from New Amsterdam Pharmaceuticals. Social determinants of health and premature death among adults in the USA from 1999 to 2018: a national cohort studyUnfavourable SDoH are associated with increased rates of premature death and contribute to differences between Black and White racial groups in premature all-cause mortality in the US population. Innovative public health policies and interventions targeting SDoH are needed to reduce premature deaths and health disparities in this population. Full-Text PDF Open Access